A Case Report & Literature Review
A Complex Injury of the Distal Ulnar
Physis: A Case Report and Brief Review
of the Literature
www.amjorthopedics.com January 2012 E1
Physeal fractures of the distal forearm are common inju-
ries in children and adolescents. However, Salter-Harris
type III and type IV fractures of the distal ulnar epiphysis
are often high-energy injuries that require open reduc-
tion for restoration of anatomical alignment. These
injuries are uncommon and there are few descriptions of
them in the contemporary literature.
Here we report the case of a 13-year-old boy with a
type IV distal ulna fracture not diagnosed with standard
radiography. After closed manipulation, an incompletely
reduced physis was suspected on the basis of fluoro-
scopic imaging and comparison radiographs of the con-
tralateral wrist. Computed tomography showed a large,
displaced physeal fragment. The patient underwent
open reduction and internal fixation.
Thorough radiographic assessment should be con-
ducted when there is a high suspicion for these fracture
patterns. Appropriate diagnosis can lead to expedient
reduction and expectant management of sequelae asso-
ciated with these injuries.
distal ulnar epiphysis fractures are generally Salter-Harris
type I or II injuries and are amenable to closed reduction
and casting. Type III and type IV fractures, however,
result from higher energy trauma and may require open
reduction and pinning for restoration of anatomical align-
hyseal fractures of the distal forearm are com-
mon injuries in children and adolescents. Most of
these fractures result from low-energy trauma and
involve both radial and ulnar epiphyses. Isolated
ment. These injuries are uncommon and there are few
descriptions of them in the contemporary literature.
In this article, we report the case of a 13-year-old
boy with a type IV distal ulnar physeal fracture with an
ipsilateral type II distal radius injury that required open
reduction and pinning. The patient’s guardian provided
written informed consent for print and electronic publi-
cation of this case report.
A 13-year-old, right-hand–dominant boy presented to the
emergency department reporting of right wrist pain. He
had fallen while running and landed on his outstretched
right hand. Physical examination revealed significant
tenderness and swelling of the right distal forearm. Wrist
and forearm range of motion (ROM) was limited by
pain. The patient was otherwise distally neurovascularly
Plain radiographs showed a physeal fracture of the
distal radial and ulnar epiphyses with 100% dorsal
displacement (Figures 1A, 1B). After closed manipula-
tion, the distal radius was anatomically reduced, but
the ulnar epiphysis appeared abnormal. Fluoroscopic
images (Figure 2) and comparison views of the con-
tralateral wrist suggested that only a portion of the
epiphysis had been reduced. Computed tomography
(CT) showed a type IV fracture of the distal ulna with
Thomas O’Hagan, MD, Deepak Reddy, MD, Waqas M. Hussain, MD, Jimmi Mangla, MD,
Alfred Atanda, Jr., MD, and Robert Bielski, MD
Dr. O’Hagan and Dr. Reddy are Orthopaedic Surgery Residents,
Section of Orthopaedic Surgery and Rehabilitation, Department
of Surgery, University of Chicago Medical Center, Chicago, Illinois.
Dr. Hussain is Sports Medicine Fellow, Department of Orthopaedics,
Sports Health Center, Cleveland Clinic, Cleveland Ohio.
Dr. Mangla is Resident, Department of Surgery, William Beaumont
Hospital, Royal Oak Michigan.
Dr. Atanda is Surgical Director of Sports Medicine Program,
Department of Orthopaedic Surgery, Alfred I. duPont Hospital for
Children, Wilmington, Delaware.
Dr. Bielski is Assistant Professor of Surgery, Section of Orthopaedic
Surgery and Rehabilitation, Department of Surgery, University of
Chicago Comer Children’s Hospital, Chicago, Illinois.
Address correspondence to: Thomas O’Hagan, MD, 3511 N.
Wilton Ave. Apt. 2 Chicago, IL. 60657 (tel, 773-710-7894; fax,
773-702-4384; e-mail, email@example.com).
Am J Orthop. 2012;41(1):E1-E3. Copyright Quadrant HealthCom
Inc. 2012. All rights reserved.
Figure 1. Injury anteroposterior (A) and lateral (B) radiographs
of wrist show fractures of distal radius and ulna with 100%
dorsal displacement of physes.
E2 The American Journal of Orthopedics® www.amjorthopedics.com
T. O’Hagan et al
volar displacement of the lateral half of the epiphysis
(Figures 3A, 3B). The patient was taken to the operat-
ing room the next day for open reduction and pinning
(Figures 4A, 4B). Soft tissue and periosteum were inter-
posed at the fracture site and attached to the displaced
epiphyseal fragment. After removal of this debris, the
remaining ulnar epiphysis was reduced. The unstable
fracture was subsequently fixed with 2 Kirschner wires
and the distal radius was also pinned to confer added
stability. The patient was placed into a long arm cast
and discharged home the next day.
Three weeks after surgery, the reduction was main-
tained, and there was evidence of interval fracture heal-
ing. At 8 weeks, the fracture was further healed and the
pins and cast were removed. At 6 months, the fracture
was fully healed and the patient demonstrated full
ROM and no limitation of activities, though distal ulna
growth arrest with ulnar negative variance was noted on
The incidence of high-energy distal ulnar epiphyseal frac-
tures is difficult to determine, as few numbers have been
reported. In 1934, Eliason and Ferguson1 found that only
9 of 141 physeal injuries of the long bones in the forearm
involved the ulnar epiphysis. In 1937, Lipschultz2 found
that only 5 of 106 patients with distal forearm physeal
injuries had disruption of the ulnar epiphysis. In addition,
in 1972, Peterson and Peterson3 attempted to classify these
injuries and found that, among all distal forearm physeal
injuries, the ulna was involved in only 3.6% of cases.
The anatomy of the distal radioulnar joint may
explain the low incidence of ulnar physeal fractures.4
Kasis and colleagues5 theorized that the meniscus
between the ulna and the proximal carpal row provides
a protective cushion for the epiphysis and thereby reduc-
es fracture rates. They also believed that the triangular
fibrocartilage complex helps dissipate traumatic forces
across the ulnar styloid.5
Most distal ulnar physeal fractures are uncomplicated
type I and type II injuries. These fractures are generally
managed with closed reduction and immobilization. In
the vast majority of cases, the ulnar epiphysis reduces
easily with reduction of the distal radius. It is important
to obtain plain radiographs, with the patient out of
plaster, to adequately visualize the extent of the frac-
ture. In this case, cast material obscured the detail of
the ulnar epiphysis, and the extent of the injury might
have been missed had the preimmobilization fluoroscopic
images not been examined closely. Radiographs of the
contralateral extremity may also be useful for com-
parison purposes. CT can identify small fragments or
intra-articular extension. In this particular case, CT
was used because the entire ulnar epiphysis could not be
visualized, and an adequate closed reduction could not
be obtained. Soft tissue, periosteum, tendon, or joint
capsule interposition may complicate these injuries.
Open reduction would then be required to ensure ana-
Type III and type IV fractures are more complex
and may require open reduction with or without inter-
nal fixation. These injuries are rare, and there are few
descriptions of them in the literature. Kasis and col-
leagues5 described the case of a 12-year-old boy with a
type IV fracture of the distal ulna and an intact distal
radius. The patient underwent open reduction and inter-
nal fixation and was stabilized with cast immobilization.
At 1-year follow-up, he had full ROM, but radiographs
showed premature closure of the ulnar epiphysis, and
an abnormal ulnar styloid and ulnocarpal joint. Engber
and Keene6 reported the case of a 15-year-old girl with
an isolated, displaced type III fracture of the distal ulnar
epiphysis after motorcycle trauma. When closed reduc-
tion was unsuccessful, open reduction with cast immo-
Figure 2. After closed
manipulation in emergency
fluoroscopic radiograph of
wrist was suspicious for
incompletely reduced distal
ulna with possible split of
Figure 3. Sagittal (A) and coronal (B) computed tomography of
wrist confirmed fragment with persistent volar displacement
consistent with lateral ulnar epiphysis. Arrows indicate displaced
bony fragment (A) and empty space created by its absence (B).
www.amjorthopedics.com January 2012 E3 Download full-text
A Complex Injury of the Distal Ulnar Physis
bilization was performed. At final follow-up, a portion
of the distal ulnar epiphysis was prematurely closed,
and partial wrist and forearm ROM was lost. Faraj and
colleagues9 described the case of a 14-year-old boy with
a displaced, rotated type IV fracture of the distal ulna
and a nondisplaced distal radius metaphyseal fracture.
During surgery, they noted a rotated fragment that had
migrated dorsally and proximally with interposed soft
tissue at the physis. Reduction was maintained with 3
Kirschner wires and a long arm cast. At 6-month fol-
low-up, the patient had full ROM but premature fusion
of the central ulnar epiphysis was documented.
Despite reported satisfactory results after closed or
open reduction and pinning of these injuries, complica-
tions related to weakness, decreased ROM, and prema-
ture ulnar physeal closure are prevalent. Golz and col-
leagues8 reviewed the cases of 18 patients with injuries
involving the distal ulnar physis. Type III fractures were
the most common, with premature physeal closure and
ulnar shortening occurring in 55% of patients. However,
most of the patients were clinically asymptomatic and
had only cosmetic reports. Nevertheless, more serious
complications, such as radial bowing, ulnar angulation
of the distal radius, and ulnar subluxation of the carpus
resulting in pain, decreased grip strength, and decreased
wrist ROM, have all been reported.8,10-12 In these cases,
management is individualized on the basis of age, degree
of deformity, amount of pain, and loss of function.
Surgical indications include progressive ulnar angulation
of the distal radial articular surface, loss of motion, and
poor cosmesis. The main goal in surgical management
is to restore the relationship between radius length and
ulna length. Surgical options include complete or partial
epiphysiodesis of the distal radius, corrective radial clos-
ing wedge osteotomy, ulnar lengthening, and a combina-
tion of these procedures.8,11-13
Although injuries of the distal forearm are common in
children and adolescents, complex physeal fractures of
the distal ulna are exceedingly rare. Some of these injuries
can be managed with a closed procedure. However, the
majority require open reduction and pinning for restora-
tion of anatomical alignment. Thorough radiographic
assessment should be performed so that the fracture
pattern can be adequately characterized. CT and con-
tralateral radiographs should be obtained in equivocal
cases. Outcomes after closed and open management of
these injuries are usually satisfactory. Parents and patients
should be informed that complications such as decreased
ROM, diminished grip strength, and premature physeal
closure, though not uncommon, seldom result in signifi-
cant functional limitations. Serial radiographs and regular
follow-up are important in identifying and managing any
authoRs’ DisClosuRe statement
The authors report no actual or potential conflict of inter-
est in relation to this article.
1. Eliason EL, Ferguson LK. Epiphyseal separation of the long bones. Surg
Gynecol Obstet. 1934;58:85-99.
2. Lipschultz O. The end-results of injuries to the epiphyses. Radiology.
3. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphy-
seal growth plate. J Trauma. 1972;12(4):275-281.
4 Ogden JA, Beall JK, Conlogue GJ, Light TR. Radiology of postnatal skeletal
development. IV. Distal radius and ulna. Skeletal Radiol. 1981;6(4):255-266.
5. Kasis AG, Hekal WE, Mubashir A. Isolated Salter-Harris type IV fractures of the
distal ulna in a 12-year-old boy. Eur J Trauma. 2004;30(2):127-129.
6. Engber WD, Keene JS. Irreducible fracture-separation of the distal ulnar
epiphysis. Report of a case. J Bone Joint Surg Am. 1985;67(7):1130-1132.
7. Evans DL, Stauber M, Frykman GK. Irreducible epiphyseal plate fracture of the
distal ulna due to interposition of the extensor carpi ulnaris tendon. Clin Orthop.
8. Golz RJ, Grogan DP, Greene TL, Belsole RJ, Ogden JA. Distal ulnar physeal
injury. J Pediatr Orthop. 1991;11(3):318-326.
9. Faraj AA, Kumar MS, Ketzer B, Rawes M. An irreducible Salter-Harris type IV
distal ulna fracture. Injury. 2000;31(9):746-748.
10. Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal forearm
fractures in children. J Pediatr Orthop. 1996;16(2):195-200.
11. Bell MJ, Hill RJ, McMurtry RY. Ulnar impingement syndrome. J Bone Joint
Surg Br. 1985;67(1):126-129.
12. Bell MJ, McMurtry RY, Rubenstein J. Fracture of the ulnar sesamoid of the
metacarpophalangeal joint of the thumb—an arthrographic study. J Hand Surg
13. Noonan KJ. Ulnar growth arrest after distal radius and ulna fractures. In: Price
CT, Flynn JM, Noonan KJ, Waters PM, eds. Complications in Orthopaedics:
Pediatric Upper Extremity Fractures. Rosemont, IL: American Academy of
Orthopaedic Surgeons. 2004:7-12.
Figure 4. Postoperative anteroposterior (A) and lateral (B)
radiographs of wrist. After open reduction, fractures were sta-
bilized with Kirschner wires.
This paper will be judged for the Resident Writer’s Award.